Recently, I was fortunate to attend the Global Symposium on the Role of Physicians and National Medical Associations in Addressing Health Equity and the Social Determinants of Health held in London, England. The meeting was organized by the Canadian, British and World Medical Associations and had, among other goals, an agenda to assist public health pioneer Sir Michael Marmot in making such issues central to his upcoming role as president of the World Medical Association.
Among the attendees was Canadian Medical Association president Dr. Chris Simpson. I sat down with Dr. Simpson to explore the stories, the evidence and the politics that come into play when doctors are actors for social change.
You have an interest in the social determinants of health -- you've been talking about it in your presidency, as have the last few Canadian Medical Association (CMA) presidents. On a personal level, why does that matter to you? In your own history, what has drawn you to the idea?
There's one reason that's more altruistic and noble than the other, but I'll give you both.
I grew up in rural New Brunswick, in a town that was a "model" town. It was created because a pulp mill was built there, and there was a hydroelectric dam that basically flooded the entire community and they had to build a new community above it. It was populated with a disproportionate number of teachers and engineers and professionals, and there was a time when I was a kid when it was the community with the highest per capita family income in the country, right in the middle of rural New Brunswick. But around it were very poor rural communities, and the contrast was incredible.
When I went to school we all were together, so you'd have these children of university educated engineers and managers making high wages next to more socio-economically disadvantaged kids. And the contrast, I can remember as a kid, struck me as just absurd. It was almost a caricature of the income gap in Canada.
I didn't understand at the time what it was, of course, but I remember being very acutely aware that there was something very odd about the dichotomy.
My father was a teacher, so I was one of the more privileged kids, grew up in a stable home, I had everything you could possibly need to build a good me. But the contrast really informed my views of the world and helped me to develop a sense of responsibility, so that's maybe the more noble reason.
From a health care perspective, it occurred to me recently that as a sub-sub-specialist who does high-tech, very expensive care that probably delivers very little incremental value to a small number of people for a very high price, and, having been very privileged because that's always been valued very highly in our society, the fact of the matter is that, increasingly, I realize that I'm not going to be able to do any of that high-tech medicine unless we find a way to better support the larger number of patients who need low-tech, but equally important care.
I'm not going to be able to do my part of things unless we address the social determinants of health as well, because it ties in critically to the sustainability of our health care system.
So that's why I say it's less than noble, because it seems a bit selfish to say. But I recognize that in a system of finite resources we're investing far too much proportionately in the stuff that I do and in doing so we're going to create an unsustainable system where we're not going to have the upstream stuff or the downstream, it's just all going to collapse.
It didn't take very much for me to see that addressing the social determinants is a critical part of a plan to achieve stability in the health care system, which gives me some hope that it's an easily translatable message -- if we could just find a way to get it out to the population better than we have.
Are you seeing some of that uptake? In the work you do through the CMA, are you seeing that idea of the determinants of health and the importance of it for our patients catching on?
I don't, and I think part of the problem is we're travelling in groups that largely have drunk the Kool Aid, but I know if I go back to my hospital-based colleagues, if I mention any of this at all, they typically do not see how an appreciation of the SDOH ties into their jobs or how it links into their role in caring for patients. We have a lot of work to do.
Family Physicians, I think, get the message very quickly, they don't have to be told or directed or instructed, they just inherently feel it. But in the specialist and hospital-based community, it's still largely a foreign concept. They understand poverty, they understand nutrition, they understand all of that intellectually, but I don't think they always feel it politically or in their gut as something that is or could be their responsibility as physicians.
What do you think would be ways that we could make physicians aware of their role in addressing the social determinants of health, and make it easier to act?
Part of it is the silos; we talk about teams, but in hospitals we're still not there yet. We try to have more interdisciplinary rounds but they're very difficult to organize. As long as we still have a silo mentality, those kinds of questions are going to be someone else's responsibility.
I like the idea of clinical tools and checklists. The surgical world and the procedural world intuitively get the notion of a checklist with safety in mind. I think you could pull out the same kind of sensibility from people if you said, "ok we're going to have a checklist that will pull out the social determinants and barriers." It could be just a list of 4 or 5 things, that's the kind of thing that could tweak the surgical mindset.
In a very insulated hospital environment, if those issues, like inability to pay for drugs, do come to light by whatever means, then the fix is the social worker. They're right there, you call them up, so you have access to support -- it should be an easy gap to close.
After a heart attack, there are 5 drugs that you have to take - the aspirin, the statin, the anti-platelet, the beta-blocker, and the ACE-inhibitor. I've had on more than one occasion, a conversation with patients saying that, if money concerns come up: "If you have to ration these, if you've got to stop some, this is the order with which I would peel them off." It seems ludicrous to say that, but to me that's a very practical intervention that is doing some good...It's less good, of course, than an approach that would find a way for them to get all five drugs.
So that's a real-world solution versus an ideal world solution like Pharmacare. I'm wondering what your thoughts are on a first dollar system, with universal coverage removing the necessity for patients to pay for prescriptions at the point of care.
The CMA position has been supporting the Kirby approach - which is some sort of catastrophic coverage. This would perhaps be a good start. But I find the arguments in favour of first-dollar coverage very compelling, personally. I was impressed by the Gagnon report and I love the paper from Danielle Martin and Steve Morgan.
First dollar coverage makes much more sense to me from an effectiveness point of view at the bedside. I've seen just a $12.99 dispensing fee dissuade people from filling their prescription. It's hard enough to get people to take their drugs, let alone having a financial barrier of a few bucks. I'm encouraged by the suggestion and the widespread belief by a lot of people that it can be economically viable to have a 1st dollar coverage system.
I'm curious about your experience as a physician and your relationship to the CMA. What changes have you seen in the organization?
One incredible turning point, which has certainly influenced my involvement with the CMA, was Jeff Turnbull's presidency. I don't think people fully appreciate yet how fundamentally that changed the organization in a way that I think is really progressive. I believe really strongly that if we just simply reflect back to our membership what we think they already think and know, that's not even remotely leadership. This isn't to say that CMA does not have a proud history -- because it does. Nor is it saying we haven't had great presidents, because we have. But the consistency we have seen over the past few years in moving ahead with a progressive agenda is what has changed.
In five short years, it's turned around completely where we're actually actively bringing along the membership -- we're talking about things that are important to society and we're no longer afraid to take risks. It's become a very progressive organization because, although we've got 1300 policies dating back to about 1921, I think the heart of the organization is definitely in a very progressive space. I've been pleasantly surprised that the membership is very happy with that change of direction. And I think it's affected the type of people who are seeking the presidency too. People who hold a different view about the role of private investment and so on who used to have quite a strong voice in the organization are now much less influential. That may be good or that may be bad, but it's certainly reflective of the type of people that are being attracted to leadership positions in the CMA; the committees, the board, in elected positions -- they've been, on the whole, more progressive and equity-minded individuals, in my opinion. There is room, of course, for all views in the CMA, but the balance we have now more accurately reflects the distribution of views of our membership, I believe.
There are two ways a medical association can see itself: As advocating for its members almost uniquely vs. seeing health as our primary goal & a healthy society. What do you see is the value of that conversation?
I think it's critical. I don't know if you noticed the sign on the wall somewhere here at the British Medical Association; it says something to the effect of "We put doctors at the center of everything we do". We recently went through a rebranding of our mission and values. I argued very strongly that we needed to leap from being doctor-centred to being very explicitly patient-centred and we kind of landed on "Helping doctors help patients" which is fair enough, but it's sort of that middle ground.
I think our legitimacy in society, which is really going to be the only way we're ever going to be truly effective as change agents, is going to be determined by whether or not people truly believe that they are our first priority. Not just individual patients, but society at large. The CMA is well on its way to getting there. And we're partially helped by the fact that all of the negotiation stuff is at the provincial level (unlike in some countries), so we're a little more free to be in that patient advocacy space instead of doctor advocacy/negotiation. They shouldn't be mutually exclusive, but physician pay can be a polarizing issue during stressful times. And as important as these issues are, it sometimes serves to distract from the advocacy piece. Take the recent dispute between the OMA and the provincial government, for example. The OMA has laid out a compelling case for why the government's imposed solution will reverse several years of funding and structural reforms designed to get better care for patients; work done between the OMA and government as a partnership. This most recent dispute reverses a lot of that good work and the OMA rightly points this out. But the issue has been reduced to soundbites in the press about a dispute over physician's pay when it's not really that at all. We support our Provincial and Territorial Medical Associations one hundred percent but our mandate to pursue advocacy is largely unencumbered by the thorny issues surrounding physician pay, and that gives us a different kind of platform from which to pursue our advocacy agenda.
Our core work is advocacy, and the other thing that's really helped us, is that we've spun off this new co-organization -- Newco -- the products and services stuff, and MD Financial Management. Those two entities (though they're wholly owned by the CMA) now have their own boards, their own CEOs. So now the CMA is all about patients, the public, and the profession's role in the service of patients and the public. We can be very much in that space. It's a very comfortable spot to be in.
Since the Turnbull presidency, the CMA has really started to own an advocacy mandate. We're feeling more and more comfortable in our own skin in that role with every passing year. You can feel it. Even at the board level -- the things they're proud of are the ones where CMA has really been out in front on an issue and helped shape society's discussion. The recent and still ongoing national conversation on end-of-life care is a great example.
One of the things that I've been seeing happen lately is a series of articles suggesting that public health professionals are commenting on the economy when they shouldn't, and that we should stick to our needles. You talked about that legitimacy of physician voice. Should we stick to our needles, or is there a role for us to be talking beyond healthcare, to the causes of ill health and the causes of the causes?
I see it a little differently than has been expressed by others. I think we need to earn the right to be in that space. We earn the right from the people we serve. So if we have expertise, and our hearts are in the right place, then civic Canada will confer the legitimacy we need to speak from that perspective.
I think we are truly servants, public servants, and we need to earn that trust. I see it less as a matter of should we or shouldn't we but rather can we earn the right to speak on these broader issues. I think we have to do a lot of hard work to really belong there - to be authentic advocates for patients and the public. I think we're well on our way, though. Essentially, whatever affects the health of Canadians should concern us. Things like the economy and tax policy and public policy in general certainly qualify as health influencers, so those of us who feel strongly about this and who have expertise can make their case to Canadians that they can help lead the discussion. Canadians will return that authenticity with their trust.
There definitely is some past baggage to overcome and some existing problems within the profession to overcome, but I think that's something the public will want from us if we approach it -- as you say -- consistently and legitimately.
And it has to be about coming at it from an altruistic perspective. Yes, we can see the link to our core business -- the practice of medicine -- but I think there's also a more general leadership role in society that - whether we have deserved it or not - we've been given historically. It's a trust. Even the right to self-regulate is a huge privilege that we have and with that comes the responsibility to do it well.
If you think about history -- physicians and their organizations have been brought along reluctantly on too many issues of progressive social change. But now we have an opportunity to provide leadership to support and develop a progressive and healthy society and further cement the trust that Canadians place in us as a profession. The stuff we're talking about here today - the role of physicians and their organizations in addressing the social determinants of health, actually has us a bit out in front of general society.
We had the refugee actions in the last few years. It was the 50th anniversary of Medicare -- physicians were out with placards -- and this time in support of universal healthcare for all instead of against it.
I'm sure you know the story of how Tommy Douglas came to really believe in Medicare - was his own experience as a kid. He received what he regarded at the time as a charitable donation of services by a doctor and in many ways, I think that kind of sensibility in the profession shares a lot of commonality with some of the core principles of most of the world's great religions; the sense that we have a responsibility to advocate for people who are less well advantaged. That sense of duty to society's most vulnerable people is deeply-rooted in our profession. Somehow, along the way, though, we've taken the privilege we've been given and we've perhaps not always lived up to the responsibility -- at a societal level -- that goes with it.
This is really all about bringing that duty and that responsibility to a whole new level. I love to see physicians with placards -- being not only advocates but activists. That's the kind of leadership that demonstrates tangibly to the people we serve that we are with them and that we will work alongside them to achieve the change our country needs.
I think we know what the right thing to do is, we just have to have the bravery and put the hard work in to make it happen.
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